Family Med

For those of you interested in how our M2 year ended. We ended on a slide with a penis pump. Go figure.

So, the day before yesterday, we talked about social responsibility as physicians and what we can do about fixing the health care system. A number of suggestions came up.

- Do what we do best and keep at it. Whatever it is, neurosurgery, family med, subspecialty in internal med, general surgery. Ultimately, if we don't love what we do and do what we do best, we're not maximizing our potential. The capitalist argument, basically. And this isn't a bad argument, either.

- Do Family Med. This is the area that needs the most people because, quite frankly, the best and the brightest are being lured into medical subspecialties and surgical specialties. And there are a lot of issues out there that we need to take care of at the primary care level that affects the lives of people. This is the altruistic argument.

- Political Advocacy. This is the area that we could all do work in. Find out about the politics and policy processes involved. Talk to people that actually know what's going on. Learn from them and from everything in the news about your own world with regards to health care and everything else. It means a lot to be able to think about politics and policies when they affect our health system and our way of life. This is the realistic option.

So out of these three, I want to blog more about the second one. Mainly because political advocacy stuff is really a responsibility for all of us as citizens and as participants in society and doing what we are best at and what we love should always be a personal goal.

Family medicine has a ton of problems going for it. We could talk all day long about this realm of healthcare. But it's only after you've gotten through all the academic literature and reading the news for years does all of these things start to fit together like a jigsaw puzzle coming together. So I'll just talk about a few of the big things and how everything just drives the way things are going in this country. If none of this is terribly coherent, bear with me, none of this is actually proofread or outlined before it is written. Think 1st draft, stream of consciousness.

Okay, so we all know that primary care docs are the ones that get paid the least of all the specialties in medicine. But I mean, it's not horrible pay, it's still 6 figures, albeit on the lower end of the $100K. But if you compare the numbers to highly lucrative specialties like Plastic Surgery or Dermatology, the difference is like 4-6 times more. The reason why the pay is so different is because of the way the insurance system is being set up. Insurance companies and America as a whole seems to believe that if you perform a procedure, you should get paid and if you perform an elective procedure, insurance should not cover it. Which all seems to make sense at first glance, why would I pay you when you haven't physically done anything to the patient, right? But this is where the logic fails, the entire process of diagnosis requires the proper set of questions, relationship building with the patient, and an astute clinician to detect subtle differences between a malignant process as opposed to a more benign one and send the patient off to the right place. But does a doctor get paid for making the right call on what your diagnosis is? No, he/she gets paid for the visit and giving you a prescription and whatever small procedure that he/she performed on you.

What's worse is that these are covered services. Preventive check-ups that would potentially save your life or extend your life for at least 10-20 years. But payments aren't measured by how much good you actually do for a patient, but how much work it took to physically do whatever procedure you just performed. And covered services are negotiated with insurance companies or set by government programs for how much a physician gets paid for whatever services or visits. Let's put in a few numbers here, say a procedure costs $200 bucks if the patient pays the doctor in cash. But an insurance company would negotiate the price down to about $150 and patient pays $10 copay. Sounds pretty reasonable, doctor gets more patients by being in the network to make up for the price difference and patient comes to get the procedure done for a lot cheaper. Everyone wins. However, when the numbers get shifted down farther in other programs like Medicare which would sound like something around $120? It's manageable, but not unreasonable. And the patient doesn't really have to pay anything. However, when you bring in Medicaid, that's when you find problems. Medicaid gives the doctor something like $80 and patient doesn't pay anything. The procedure probably costs $79 for the materials alone. But you take these patients on because you have a heart. So now there's no incentive for the doctors take on medicaid patients beyond that of simply being a good person and wanting to take care of people that need health care.

Now, you already see the problem, if a doctor starts taking care of more medicaid patients in like an inner city clinic, he'll run into problems with finances of paying his office staff and his own salary. So the numbers can be driven farther down than that low $100K salary. So the system itself doesn't encourage us to go into underserved communities such as the inner city or the rural regions solely on a financial basis.

So, with the financial incentive entirely missing from becoming primary care in areas that need it, the only reason anyone would do it is because they can survive on a lower than 6 figure salary. And you ask me why this should even be an issue? Why would anyone need more than $50K a year?

So let's do the math on how much medical education costs and how much time it takes to go into medical school.
Out of State tuition or Private School tuition: $40K per year
Living expenses: $12K per year if you're good
for 4 years, this comes out to be $52K x 4 --> $208K + interest at about 8 percent right now... I'll just do the math for you so you don't have to plow through all of this.

I think it comes out to be about $300K if you borrowed everything to pay for school with interest compounding yearly (it's probably quarterly, but I'm too lazy to do that math).

[Editing note: interest is compounded monthly, so it's even worse; let's just put it at around $350K]

Of course, the interest rates are still going on while you're in residency. So, a decent residency will pay you about 50K a year at 80 hours per week and upped about 3-5K a year depending on the specialty, I think. So, at 8% interest $24K is your interest and you have to pay for food and housing and all that good stuff with taxes.

That put you at income (50K) - interest (24K) - living expense (12K) - income tax (6.6K) = $7.4K to spend on paying down the principal.

But of course, this is just for people that have already paid off their college loans. Now the numbers really look bad.

So after residency and living like a college student for all those years, you would still have at least 250K of the med school loans (and college loans) to pay off at that point. Where's the incentive now to work in low income neighborhoods?

Until the financial incentives to work in family med catch up to the high debt amounts a med student has, there's not really much going into primary care.

And this is why as a person that can do basic math, I'm not motivated to do primary care. It's going to be hard to find someone else that's paying for this sort of tuition and loan expenses to do so, too. If you care about your health care, call your congress person to fix this.